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Pre-Travel Visit Worksheet
University of Missouri Student Health Center
1020 Hitt St.
Columbia MO 65201
Phone 573-882-7747 or 573-882-4661
Fax 573-884-8902
Name: MU ID # Current phone #
The information you provide on this form allows the Student Health Center’s Staff to prepare for your upcoming Travel
Visit and assess your immunization and other travel needs.
Return the completed form, along with the most current copy of your immunization record, to the MU Student Health
Center by fax (573-884-8902) or email as an attachment. Once we receive the completed form and immunization records,
the staff will call you to schedule your appointment. Please note the visit may take up to one-hour.
To help clarify any potential questions, please bring copies of your immunization records to the appointment. This should
include childhood to present, including any additional shots you may have had since originally turning in your records
upon entrance to the University of Missouri.
Please respond completely and thoroughly.
Date of departure: Date of return:
Purpose of trip (check all that apply)
Organized group travel Independent travel
Vacation Education/research Visit friends or family
Missionary/volunteer/humanitarian Work Other
Will you be:
Visiting areas that are:
Rural Yes No Not sure
Urban Yes No Not sure
Primitive or remote Yes No Not sure
Ascending to high altitudes (8,000 ft. or higher)? Yes No Not sure
Working with potential exposure to body fluids (e.g., medical or dental work)? Yes No Not sure
Working with animals or insects? Yes No Not sure
Doing fieldwork? Yes No Not sure
Potentially having new sexual partners? Yes No Not sure
Accommodations (check all that apply):
Resort/large hotel Small hotel/guest house/B&B Cruise ship Private home
Primitive camping Up-scale camp/lodge Dormitory/ hostel Other
Previous international travel (year/destination):
